Conventional and Liquid-Based in Anal

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J Acquir Immune Defic Syndr. Author manuscript; available in PMC 2014 August 01.
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J Acquir Immune Defic Syndr. 2013 August 1; 63(4): 464–471. doi:10.1097/QAI.0b013e3182928ea6.
Comparable performance of conventional and liquid-based

cytology in diagnosing anal intraepithelial neoplasia in HIV-
infected and -uninfected Thai men who have sex with men
Nittaya Phanuphak1,2, Nipat Teeratakulpisarn1, Cherry Lim1, Taweesak Changnam1,
Stephen J. Kerr3, Amornrat Deesua1, Piranun Hongchookiat1, Piyanee Rodbamrung1,
Saranya Numto4, Jiranuwat Barisri1, Praphan Phanuphak1,2,3,5, Somboon Keelawat6,
Annette H. Sohn7, Jintanat Ananworanich1,2,3,5, and Surang Triratanachat4
1The Thai Red Cross AIDS Research Centre, Bangkok, Thailand 2SEARCH, Bangkok, Thailand
3HIV-NAT, Bangkok, Thailand 4Department of Obstetrics and Gynecology, Faculty of Medicine,
Chulalongkorn University, Bangkok, Thailand 5Department of Medicine, Faculty of Medicine,
Chulalongkorn University, Bangkok, Thailand 6Department of Pathology, Faculty of Medicine,

Chulalongkorn University, Bangkok, Thailand 7TREAT Asia/amfAR – The Foundation for AIDS
Research, Bangkok, Thailand
Abstract
Background—Anal cytology has increasingly been used to screen for anal intraepithelial
neoplasia (AIN) among men who have sex with men (MSM) at increased risk for anal cancer. Use
of liquid-based cytology has been reported to reduce fecal and bacterial contamination and air-
drying artifact compared to conventional cytology. Costs associated with liquid-based cytology,
however, may limit its use in resource-limited settings.
Methods—Anal swab samples were collected from MSM participants and used to prepare
conventional and liquid-based cytology slides. Abnormal conventional cytology results triggered
referral for high-resolution anoscopy (HRA) and biopsy. Agreement between the two cytology
techniques and the positive predictive value (PPV) ratios of histology confirmed AIN were
calculated.
Results—Among 173 MSM, abnormal anal cytology was identified in 46.2% of conventional
and 32.4% of liquid-based slides. The results agreed in 62.4% of cases with a kappa (κ) value of
0.49 (P <0.001). HIV-infected MSM had a 3.6-fold increased odds of having discordant anal
cytology results (95% CI 1.6–7.8, p=0.001) compared with HIV-uninfected MSM. Histological
AIN 2 and 3 were identified in 20 MSM. The PPV ratios and 95% CI indicated no difference
between the two techniques.
Conclusions—Conventional anal cytology may be a preferred option for resource-limited
settings given comparable performances to liquid-based cytology for the detection of AIN,
although the agreement between the two techniques was lower among HIV-infected MSM. Due to
high prevalence of abnormal anal cytology and AIN, health systems should prepare adequate
infrastructure for HRA services and AIN treatment.
Corresponding Author: Nittaya Phanuphak, M.D., 104 Rajdumri Road, Pathumwan, Bangkok 10330, Thailand, Phone:
+662-253-0996, Fax: +662-253-0998, nittaya.p@trcarc.org.
Conflicts of Interest: Authors declared no potential conflict of interest relevant to this work.
Phanuphak et al. Page 2
Keywords
anal cytology; conventional; liquid-based; MSM
Introduction
Men who have sex with men (MSM) are at high risk of having anal pre-cancerous lesions
and anal cancer from persistent human papillomavirus (HPV) infection.1–5 Human
immunodeficiency virus (HIV) further accentuates these risks.1–7 An estimated incidence
rate of anal cancer is 35 per 100,000 person-years among HIV-uninfected MSM compared
to 70–100 per 100,000 person-years among HIV-infected MSM.8, 9 Similar to the use of
cervical cytology to screen for cervical pre-cancerous lesions, anal cytology has increasingly
been used to screen for anal pre-cancerous lesions among at-risk populations.10, 11
Low cellularity, air-drying artifact, and obscuring bacteria and fecal material are common
factors which hinder adequate evaluation of anal cytologic preparations and may result in
false-negative diagnoses.12, 13 Use of liquid-based cytology techniques has been reported to
reduce fecal and bacterial contamination and air-drying artifact in anal cytology slides
compared to slides prepared by conventional techniques.12
In resource-limited settings, use of liquid-based smears for anal cytology is limited mainly
by its related cost, therefore, conventional smears are generally the standard technique
used.14–16 The purpose of this study was to compare anal cytology results from slides
prepared by a conventional technique to those prepared by a liquid-based technique. Anal
samples were collected from HIV-infected and -uninfected MSM who received clinical
evaluations at the Thai Red Cross AIDS Research Centre in Bangkok, Thailand.
Methods
Data for the analyses in this publication were planned as part of a larger study to evaluate
the use of multidisciplinary, MSM-targeted services to enhance HIV testing and linkage to
care among MSM (MSM VCT Study, clinicaltrials.gov identification NCT01637324),
which enrolled HIV-infected and -uninfected MSM at the Thai Red Cross AIDS Research
Centre in Bangkok, Thailand. Anal histologic findings from some study participants who co-
enrolled in another study (Biomarkers to Detect Anal Intraepithelial Neoplasia (AIN) in
Thai MSM, NCT01637298) were also included in the analyses. Both studies were approved
by the institutional review board of the Faculty of Medicine, Chulalongkorn University in
Bangkok, Thailand.
Enrollment and follow-up of study participants

Thai men 18 years or older who had a history of anal sex with men, lived in or near
Bangkok, and had documented HIV status were enrolled into the two cohorts described
above. All participants gave informed consent.
Anal sample collection for anal cytology

Anal sample collection was performed at enrollment by trained study physicians and study
nurses. A pre-moistened, non-lubricated Dacron swab (Solon™, Solon Manufacturing
Company, Rhinelander, WI) was gently inserted approximately 5–8 cm into the anal canal
until it reached the transformation zone. The swab was then removed with a twirling motion,
while applying gentle pressure on the walls of the anal canal to maximize cellular yield. A
conventional anal cytology slide was prepared by rolling the swab directly onto a glass slide.
The glass slide was immediately fixed in 95% ethanol. The swab was then put in a liquid-
based cytology fluid (Liqui-PREP™, LGM International, Inc., Melbourne, FL), which was
stored at 4°C until processed within 1 week after sample collection. To prepare the second
slide, Liqui-PREP™ Cleaning Solution was added to the fluid to remove non-cellular debris
before centrifugation at 1,000 g for 10 minutes. Liqui-PREP™ Cellular Base Solution was
added to the cell pellet to encapsulate and facilitate cell adherence. A 50 µl aliqout of well
mixed, homogenous suspension was then placed on a glass slide using a pipette and dried,
resulting in a 1.5–2.0 cm diameter circle.
Anal cytology reading

Slides prepared by conventional and liquid-based techniques were stained with
Papanicolaou stain. Anal cytology slides were read by cytotechnicians, blinded to the result
of the slide prepared by the other technique, at the Cyto-pathological Unit, Department of
Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University in Bangkok,
Thailand. The results of all anal cytology slides were confirmed by one highly experienced
cytopathologist (ST). Satisfactory slides were defined as an estimated minimum of 8,000–
12,000 well-preserved and well-visualized squamous epithelial cells if prepared by the
conventional technique and an estimated minimum of 5,000 cells if prepared by the liquid-
based technique. Presence or absence of rectal columnar, blood, and inflammatory cells in
each slide were also documented. Anal cytology results were classified using the 2001
Bethesda system17 as normal, atypical squamous cells of undetermined significance (ASC-
US), atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion
(ASC-H), low-grade squamous intraepithelial lesion (LSIL), high-grade squamous
intraepithelial lesion (HSIL), or carcinoma.
High resolution anoscopy and biopsy

Participants who had abnormal anal cytology results from ASC-US and above from
conventional method in the MSM VCT Study had high resolution anoscopy (HRA)
performed within 3 months of their enrollment visits. Participants who were enrolled in the
Biomarkers to Detect AIN in Thai MSM study had HRA performed at their visits, regardless
of anal cytology results. Acetic acid solution and Lugol's solution were used to aid
visualization of abnormal anal tissue for biopsy. Histology results were read by pathologists,
specializing in anal tissue pathology, at the Department of Pathology, Faculty of Medicine,
Chulalongkorn University in Bangkok, Thailand. The highest histologic grades reported for
each participant were used for data analyses.
Statistical Analysis
Statistical analysis was conducted with Stata version 11.2 (Statacorp, College Station, Tx.
USA). Baseline characteristics of HIV-infected and HIV-uninfected participants were

compared using Fisher's exact test, Mann-Whitney U test, or Chi-square test as appropriate.
Anal cytology and anal histology results were evaluated for correlation when samples from
the same participants were available. Logistic regression was used to identify potential
variables associated with discordant anal cytology results. The kappa statistic was calculated
to identify the level of agreement between the conventional and liquid-based cytology tests,
and a weighted kappa was calculated to assess the overall ordinal pairwise grading of the
cytological results, weighting a disagreement by one diagnostic category by 0.67 and by 2
diagnostic categories by 0.33. The analysis was done on the same population, and thus
prevalence is shared in the positive predictive value (PPV) calculations, and for this reason,
we used PPV ratios to make inferences about differences in specificity between the two
cytology tests. Confidence intervals (CI) around the ratios were calculated according to a
binomial distribution.
Results
Participant characteristics
Between 18 May – 30 July 2011, we enrolled 179 MSM participants. Three participants
were excluded from the analyses because they had another anal sample collection just prior
to the Dacron swab collection for cytology (Figure 1). Another three participants were
excluded because the duration between the initial Pap smears and histological follow-up
exceeded 3 months. Among 173 participants included in the analyses, 118 were HIV-
infected MSM and 55 were HIV-uninfected MSM (Table 1). Median age at first sex was 18
(interquartile range, IQR 15–20) years. Median number of sex partners within the past
month was 1 (IQR 1–3), and 38.2% had receptive anal sex in the past month. Consistent
condom use in the last month was reported by 43.9%. HIV-infected MSM were older than
HIV-uninfected MSM (median age 35.5 vs 32 years, P = 0.02). Of HIV-infected MSM,
44.3% were currently on highly active antiretroviral therapy (HAART). Median CD4+ cell
count (CD4 count) was 391 (312–549) cells/mm3 and median plasma HIV RNA was 1.60
(1.60 – 4.15) log10 copies/ml.
Correlation of anal cytology results from slides prepared by conventional versus liquid-
based techniques
Combining data from HIV-infected and -uninfected MSM, there was no unsatisfactory slide
among those prepared by conventional technique, while 3 (1.7%) slides prepared by liquid-
based technique were considered unsatisfactory (Table 2). Abnormal anal cytology from
ASC-US and above was identified in 80 of 173 cases (46.2%) from conventional slides and
in 56 (32.4%) from liquid-based slides. Rectal columnar epithelia were presented in 83
(48.0%) of conventional slides and 75 (43.4%) of liquid-based slides (P = 0.136). Squamous
intraepithelial lesions were diagnosed in 16.9% of slides where rectal columnar cells were
present and in 13.1% of slides without rectal columnar cells.
Anal cytology diagnosis using conventional and liquid-based slides agreed in 108 of 173
cases (62.4%), with a kappa (κ) value of 0.49 (P <0.001). Excluding 3 indeterminate liquid-
based slides, diagnosis within one and two diagnostic categories of each other was identified
in another 51 (30%) and 11 (6.5%) of slides, giving a weighted κ of 0.45, P <0.001 and an
agreement of 85.7%. When data were compared using a weighted κ between HIV-infected
and uninfected MSM, the cytology tests showed an overall lower agreement in HIV-infected
participants (agreement = 82.1%, κ = 0.39, P <0.001) than HIV-uninfected participants
(agreement = 93.2%, κ = 0.58, P <0.001).
Three cases of HSIL diagnosed from conventional slides were diagnosed as ASC-US (1),
LSIL (1), and HSIL (1) by liquid-based slides. From liquid-based slides, 9 cases of HSIL
diagnosed were read as ASC-US (2), LSIL (6), and HSIL (1) from conventional slides.
Agreement between conventional and liquid-based slides for abnormal results from ASC-US
and above was 75.1% (κ = 48.7, P <0.001), 69.5% (κ = 40.3, P <0.001) for HIV-infected
MSM and 87.3% for HIV-uninfected MSM (κ = 65.8, P <0.001). For abnormal results from
LSIL and above, agreement between both techniques was 88.4% (κ = 46.4, P <0.001),
85.6% for HIV-infected MSM (κ = 46.4, P <0.001) and 94.6% for HIV-uninfected MSM (κ
= 37.3, P = 0.0024). Agreement was 94.2% (κ = 14.4, P = 0.01) when results were read as
HSIL and above, 92.4% for HIV-infected MSM (κ = 15.0, P = 0.03). There was no HSIL
cases read from conventional cytology among HIV-uninfected MSM.
Being HIV-infected MSM was the only factor that was correlated with a higher risk for
discordant anal cytology results by univariate analysis (OR 3.6, 95% CI 1.6–7.8, p=0.001).
Amongst the socio-demographic and behavioral characteristics presented in Table 1, there
were no association with discordant anal cytology results. Within the HIV-infected MSM,
CD4 count, plasma HIV RNA levels and being on antiretroviral therapy were also not
associated with discordant anal cytology results.
Detection of histologically confirmed AIN by abnormal conventional and liquid-based anal

cytology results
Of 173 participants, 96 (55.5%) had HRA and 69 (40.0%) had biopsies performed (Table 3).
By histology, AIN 1 was identified in 33 cases (47.8% of 69 participants who had biopsy
performed) and AIN 2 and AIN 3 were identified in 20 (29.0%). The remaining (23.2%) had
normal or benign histologic diagnoses. Of 20 AIN 2 and AIN 3 cases, 1 AIN 2 case and 6
AIN 3 cases had HSIL diagnosis by either conventional or liquid-based slides. ASC-US or
higher-grade cytologic diagnoses could detect 17 AIN 2 and AIN 3 cases by conventional
technique and 14 AIN 2 and AIN 3 cases by liquid-based technique (Table 4).
PPVs of abnormal conventional and liquid-based anal cytology for detecting histologically
confirmed AIN
By conventional cytology, ASC-US had 28.3% and LSIL had 39.1% PPVs in predicting
histologic AIN2 and AIN 3, while HSIL had 50% PPV in predicting histologic AIN 2 and
AIN 3 (Table 4). Using liquid-based cytology, ASC-US had 37.8% PPV, LSIL had 46.2%
PPV, and HSIL had 66.7% PPV in predicting histologic AIN 2 and AIN 3. The 95% CI
around the PPV ratios indicated that the PPVs of liquid-based versus conventional cytology
were not significantly different.
For HIV-infected MSM, the PPVs were 29.4% for ASC-US, 38.1% for LSIL, and 50.0% for
HSIL in predicting AIN 2 and AIN 3 by conventional cytology and were 40.0% for ASC-
US, 41.7% for LSIL, and 62.5% for HSIL by liquid-based cytology. The PPVs were 22.2%
for ASC-US and 50.0% for LSIL by conventional cytology and 28.6% for ASC-US, 100%
for LSIL, and 100% for HSIL by liquid-based cytology to predict AIN 2 and AIN 3 among
HIV-uninfected MSM. The 95% CI around the PPV ratios did not indicate significant
differences between the two techniques when used either in HIV-infected or HIV-uninfected
MSM.
Discussion
Our study demonstrated that anal cytology results read from slides prepared by a
conventional technique had good correlation with those prepared using a liquid-based
technique. In resource-limited settings, use of conventional Pap slides for cytology
evaluations is more practical due to the high cost of liquid-based cytology fluid and
associated equipments. The LiquiPrep™ solution used in the study provides an additional
advantage over other liquid-based cytology fluids in terms of cost, because an automated
slide preparation machine is not needed.
For cervical cytology, liquid-based cytology techniques have been shown to provide
greater 18–20 or at least equivalent diagnostic accuracy compared to the conventional
smear.14 Studies on the use of liquid-based cytology techniques for anal cytology, however,
are more limited. Use of ThinPrep® was shown to yield similar diagnostic results compared
to conventional smears for anal cytology, although ThinPrep® provided additional benefits
in reducing fecal and bacterial contamination and air-drying artifact.12, 13
Previous studies have shown a wide range of unsatisfactory rates of anal cytology slides
prepared by conventional techniques (17–24%)12, 13 and liquid-based techniques (7–
17%).12, 13, 21 Rectal columnar cells, an indicator that the rectal transformation zone was
adequately sampled, were found more frequently on liquid-based cytology slides than
conventional slides in several studies.12, 13, 22 The presence of an adequate amount of well-
preserved and adequately fixed cells , however, may be as important as the presence of cells
from the transformation zone when evaluating the sample quality of anal cytology slides.13
We found a very low unsatisfactory rate for both conventional (0%) and liquid-based slides
(1.7%) for anal cytology, given that the presence of rectal columnar cells was not a
requirement for our study.
We identified more abnormal anal cytology cases from conventional slides than from liquid-
based slides, although more ASC-H and HSIL cases tended to be diagnosed from liquid-
based slides. This is in contrast to previous findings which showed equal or higher detection
rates of abnormal anal cytology with the use of liquid-based techniques because of reduction
of fecal material, inflammation, bacteria, and air-drying artifact.12, 13 The detection rate of
SILs from ThinPrep slides in one study was shown to be nearly eight times higher than
conventional slides.13 This may be due to the different technique used for LiquiPrep™, as
the smear was made manually using a pipette, which may not result in a thin, evenly
dispersed monolayer of cells seen with semi-automated liquid-based slide preparation and
the amount of cells obtained on the slides may be less. ThinPrep® and SurePath™ slides
were prepared by a processor that mechanically disperses the cells, which are then drawn
onto a filter by negative pressure and transferred onto a glass slide in a monolayer. In
addition, the amount of cells available in our liquid-based cytology fluid may have been
reduced by the antecedent preparation of the conventional anal cytology slide. However, this
was not found to be an issue in a previous study.12
A systematic review did not show significant differences in sensitivity and specificity of
anal cytology to detect abnormal histologic diagnoses between conventional and liquid-
based cytology techniques conducted across different studies.10 Although we could not
comment on the absolute sensitivity and specificity in our study due to the lack of reference
testing on every participant, we found the overall agreement between conventional and
liquid-based cytology to be 62.4% and a κ value of 0.43, which showed moderate agreement
between the two techniques. HIV-infected MSM had a 3.6-fold increased odds of having
discordant anal cytology results. The overall agreement, as well as agreement when
abnormal results from ASC-US and above were considered, were lower in HIV-infected
than HIV-uninfected MSM., The PPV ratios demonstrated comparable performances of both
techniques in detecting histologically confirmed AIN, both in HIV-infected and HIV-
uninfected MSM.
Conventional cytology was able to accurately read only 1 out of 9 HSIL results on liquid-
based cytology, while only 1 out of 3 HSIL results on conventional cytology was correctly
read by liquid-based cytology. Of 20 cases who had histologically confirmed AIN 2 and
AIN 3 in our study, if referral to HRA was triggered by HSIL alone, only 1 case would have
been diagnosed on conventional cytology and 6 cases on liquid-based cytology. This is in

accordance with previous findings which showed that the grade of disease on anal cytology
did not correspond well to the histologic grade after biopsy,21, 23–26 and suggested that
MSM with screening anal cytology results that are abnormal at any grade should be
considered for HRA.24 The high prevalence of abnormal anal cytology underlies the
importance of the readiness of health systems for referral to HRA services. Setting up HRA
services is challenging in both resource-rich and resource-limited settings due to the cost and
the paucity of trained clinicians. Use of other tests such as HPV genotypes, E6/E7 mRNA,
or abnormal cell cycle markers may be useful either as a primary screening or adjunctive
screening method to anal cytology to detect high-grade AIN.27, 28 For this purpose, liquid-
based cytology provides its advantage over conventional cytology as these adjunctive tests
can be conducted from the same liquid-based cytology sample.
Our study had several limitations. We had limited statistical power to study agreement of the
two cytology techniques among subset of MSM with high-grade AIN (AIN 2 and AIN 3),
the putative anal precancerous lesions, since there were only 20 AIN 2 and AIN 3 cases. We
also could not make definitive conclusions on the performance characteristics of anal
cytology for the detection of high-grade AIN since HRA and biopsy was not performed
among the majority of MSM with normal anal cytology in this study. In addition, the
sequence of anal sample collection in our study could affect the amount of cells available for
liquid-based cytology. Ideally, the sequence of anal sample collection could have been
reversed for a subset of slides to overcome this limitation. Lastly, the reading of anal
cytology and anal histology slides in our study were not performed by the same
cytotechnician or pathologist. The interobserver agreement for anal cytology has been
reported in other studies to be moderate with a weighted κ statistic ranging from 0.72 to
0.92.29, 30 All cytotechnicians and pathologists in our study have participated in quality
control programs conducted during the course of the associated studies to minimize
interobserver variances.
In summary, we demonstrated that anal cytology results using a conventional slide

preparation technique were similar to those using a liquid-based technique, although the
agreement between the two techniques was lower among HIV-infected MSM. With low
agreement between anal cytology and histology diagnoses in general, programs which aim
to screen for high-grade AIN would need to prepare adequate infrastructure for HRA
services and treatment. The need for new biomarkers to detect high-grade AIN will become
more apparent as more screening programs are established worldwide.
Acknowledgments
The study team is grateful to the individuals who volunteered to participate in this study and to staff at the Thai Red
Cross AIDS Research Centre and the Faculty of Medicine, Chulalongkorn University. The project was supported
through a grant from amfAR, The Foundation for AIDS Research, through supplemental funding from the Office of
the Global AIDS Coordinator for the President's Emergency Plan for AIDS Relief (PEPFAR) and the Office of
AIDS Research (OAR) of the U.S. National Institutes of Health to the International Epidemiologic Databases to
Evaluate AIDS (IeDEA; U01AI069907): National Institute of Allergy and Infectious Diseases (NIAID), Eunice
Kennedy Shriver National Institute Of Child Health and Human Development (NICHD), and National Cancer
Institute (NCI). The content of this presentation is solely the responsibility of the authors and does not necessarily
represent the official views of any of the institutions mentioned above.
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22234750]
29. Colquhoun P, Nogueras JJ, Dipasquale B, Petras R, Wexner SD, Woodhouse S. Interobserver and
intraobserver bias exists in the interpretation of anal dysplasia. Dis Colon Rectum. 2003 Oct;
46(10):1332–1336. discussion 1336–1338. [PubMed: 14530670]
30. Lytwyn A, Salit IE, Raboud J, et al. Interobserver agreement in the interpretation of anal
intraepithelial neoplasia. Cancer. 2005 Apr 1; 103(7):1447–1456. [PubMed: 15726546]
Figure 1.
Flow diagram of the number of participants included in the study analyses, according to the
STAndards for the Reporting of Diagnostic accuracy studies (STARD).
Table 1
Baseline characteristics of 173 men who have sex with men enrolled at the Thai Red Cross AIDS Research
Centre, Bangkok, Thailand
Characteristics Total HIV Status P-value

n=173
HIV-infected HIV-uninfected
n=118 n=55
MSM VCT Study (n) 153 108 45

Biomarkers to Detect AIN in 20 10 10
Thai MSM study (n)
Age, years, median (IQR) 34 (28 – 40) 35.5 (29 – 41) 32 (25.5 – 37.5) 0.02
CD4 count, cells/mm3, median (IQR) n/a 391 n/a -

(312–544)
HIV RNA, log10 copies/ml, n/a 1.60 n/a -

median (IQR) (1.60 – 4.15)
Current use of HAART, n (%) n/a 78 (44.3) n/a
Education, n (%) 76 (43.9) 57 (48.31) 19 (34.6) 0.15

Lower than Bachelor's Degree 76 (43.93) 46 (38.98) 30 (54.6)
Bachelor's Degree 21 (12.14) 15 (12.71) 6 (10.9)
Higher than Bachelor's Degree
Monthly income, USD, median (IQR) 360 360 390 0.72

(240 – 600) (240 – 600) (232.5 – 600)
Age at first sex, years, median (IQR) 18 18 18 0.59

(15 – 20) (15 – 20.25) (15.5 – 20)
Number of sex partners in the 1 (1 – 3) 1.5 (1 – 3) 1 (1 – 4) 0.51

past month, median (IQR) 1 (0.6) 1 (0.9) 0 (0.0) 0.11
0 56 (32.4) 37 (31.4) 19 (34.6)
1 44 (25.4) 34 (28.8) 10 (18.2)
2–5 11 (6.36) 4 (3.4) 7 (12.7)
>5 61 (35.3) 42 (35.6) 19 (34.6)
Do not want to answer
Receptive anal sex as sexual 41 (23.7) 25 (21.2) 16 (29.1) 0.61

route in the past month, n (%) 66 (38.2) 48 (40.7) 18 (32.7)
No 3 (2.89) 3 (2.5) 2 (3.6)
Yes 61 (35.3) 42 (35.6) 19 (34.6)
No sex in the past month
Consistent condom use in the 76 (43.9) 54 (45.8) 22 (40.0) 0.57

past month, n (%) 36 (20.8) 22 (18.6) 14 (25.5)
Yes 61 (35.3) 42 (35.6) 19 (34.6)
No
IQR, interquartile range; n/a, not applicable; HAART, highly active antiretroviral therapy
NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript
Table 2
Anal cytology results from slides prepared by conventional versus liquid-based techniques, combined HIV-infected and -uninfected MSM and by HIV
status
Combined HIV-infected and -uninfected MSM

Phanuphak et al.
Liquid-based cytology
Conventional
cytology Unsatisfactory Negative ASC- LSIL HSILa Total
US
Negative 3 81 9 1 0 96
ASC-US 0 26 23 1 2 52
LSIL 0 7 8 3 6 25
HSIL 0 0 1 1 1 3
Total 3 114 41 6 9 173
HIV-infected MSM
Conventional
cytology ASC- LSIL HSIL Total
Unsatisfactory Negative
US
Negative 2 44 7 1 0 54
ASC-US 0 22 16 0 2 40
LSIL 0 6 7 3 5 21
HSIL 0 0 1 1 1 3
Total 2 72 31 5 8 118
HIV-unfected MSM
Conventional
cytology Unsatisfactory Negative ASC- LSIL HSIL Total
US
Negative 1 37 2 0 0 40
ASC-US 0 4 7 1 0 12
LSIL 0 1 1 0 1 3
HSIL 0 0 0 0 0 0
Total 1 42 10 1 1 55
ASC-US, atypical squamous cells of undetermined significance; LSIL, low-grade squamous intraepithelial lesion; HSIL, high-grade squamous intraepithelial lesion
Page 12
a
Five atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H) results among liquid-based slides were grouped with HSIL in this table. Of these 5 cases, 1 had ASC-US
and 4 had LSIL read by conventional slides. There was no ASC-H result among the conventional slides.
Phanuphak et al.
Page 13
Table 3
Anal cytology and histology results, combined HIV-infected and -uninfected MSM
Anal cytology
Anal histology Normal

Phanuphak et al.
HRA, No
No HRA Biopsy Normal AIN 1 AIN 2 AIN 3 Total
Conventional
cytology
Normal 74 11 4 2 3 0 94 (54%)
ASC-US 0 15 9 20 1 7 52 (30%)
LSIL 2 1 2 11 4 4 24 (14%)
HSIL 1 0 1 0 0 1 3 (2%)
Liquid-based
cytology
Normal 61 21 11 15 4 2 114 (66%)
ASC-US 12 5 4 12 2 6 41 (24%)
LSIL 1 1 1 3 0 0 6 (3%)
HSILa 0 0 0 3 2 4 9 (5%)
Inadequate 3 0 0 0 0 0 3 (2%)
Total
77 (44%) 27 (16%) 16 (9%) 33 (19%) 8 (5%) 12 (7%) 173 (100%)
AIN, anal intraepithelial neoplasia; ASC-US, atypical squamous cells of undetermined significance; LSIL, low-grade squamous intraepithelial lesion; HSIL, high-grade squamous intraepithelial lesion.
Percentages are rounded and may not always add up to 100%.

a
Five atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H) results among liquid-based slides were grouped with HSIL in this table. Of these 5 cases, 1 had ASC-US
and 4 had LSIL read by conventional slides. There was no ASC-H result among the conventional slides.
Page 14
Table 4
Positive predictive values of abnormal conventional and liquid-based anal cytology results for detecting histologically confirmed anal intraepithelial
neoplasia

Phanuphak et al.
Cytology Histologic Conventional cytology Liquid-based cytology

PPV ratio
result diagnosis n PPV, % (95% CI) n PPV, % (95% CI)
60 37
ASC-US+a AIN 1+b 48 80.0 (67.7–89.2) 32 86.5 (71.2–95.5) 1.08 (0.90–1.29)
AIN 2+c 17 28.3 (17.5–41.4) 14 37.8 (22.5–55.2) 1.34 (0.75–2.38)
23 13
AIN 1+b 20 87.0 (66.4–97.2) 12 92.3 (64.0–99.8) 1.06 (0.85–1.33)

LSIL+d
AIN 2+c 9 39.1 (19.7–61.5) 6 46.2 (19.2–74.9) 1.18 (0.54–2.57)
2 9
AIN 1+b 1 50.0 (1.3–98.7) 9 100 (66.4–100) 2.00 (0.50–8.00)

HSIL+e
AIN 2+c 1 50.0 (1.3–98.7) 6 66.7 (29.9–92.5) 1.33 (0.31–5.75)
HIV-infected MSM

PPV ratio
51 30
AIN 1+b 40 78.4 (64.7–88.7) 25 83.3 (65.3–94.4) 1.06 (0.86–1.32)

ASC-US+a
AIN 2+c 15 29.4 (17.5–43.8) 12 40.0 (22.7–59.4) 1.36 (0.74–2.50)
21 12
AIN 1+b 18 85.7 (63.7–97.0) 11 91.7 (61.5–99.8) 1.07 (0.84–1.37)
LSIL+d
AIN 2+c 8 38.1(18.1–61.6) 5 41.7 (15.2–72.3) 1.09 (0.46–2.59)
2 8
AIN 1+b 1 50.0 (1.3–98.7) 8 100 (63.1–100) 2.00 (0.50–8.00)

HSIL+e
AIN 2+c 1 50.0 (1.3–98.7) 5 62.5 (24.5–91.5) 1.25 (0.28–5.53)
HIV-uninfected MSM
Page 15

PPV ratio
9 7
AIN 1+b 8 88.9 (51.8–99.7) 7 100 (59.0–100) 1.13 (0.89–1.42)

Phanuphak et al.
ASC-US+a
AIN 2+c 2 22.2 (2.8–60.0) 2 28.6 (3.7–71.0) 1.29 (0.24–6.99)
2 1
AIN 1+b 2 100 (15.8–100) 1 100 (2.5–100) 1.00 (1.00–1.00)

LSIL+d
AIN 2+c 1 50.0 (1.3–98.7) 1 100 (2.5–100) 2.00 (0.50–8.00)
0 1
AIN 1+b 0 - 1 100 (2.5–100) -

HSIL+e
AIN 2+c 0 - 1 100 (2.5–100) -
PPV, positive predictive value; CI, confidence interval; AIN, anal intraepithelial neoplasia; ASC-US, atypical squamous cells of undetermined significance; LSIL, low-grade squamous intraepithelial lesion;
HSIL, high-grade squamous intraepithelial lesion
a
ASC-US+ includes ASC-US, LSIL, and HSIL.
b
AIN 1+ includes AIN 1, AIN 2, and AIN 3.
c
AIN 2+ includes AIN 2 and AIN 3.
d
LSIL+ includes LSIL and HSIL.
e
HSIL includes HSIL and atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASC-H).
Page 16

Conventional and Liquid-Based in Anal

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Conventional and Liquid-Based in Anal

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J Acquir Immune Defic Syndr. 2013 August 1; 63(4): 464–471. doi:10.1097/QAI.0b013e3182928ea6.

Comparable performance of conventional and liquid-based

Chulalongkorn University, Bangkok, Thailand 6Department of Pathology, Faculty of Medicine,

Enrollment and follow-up of study participants

Anal sample collection for anal cytology

Anal cytology reading

High resolution anoscopy and biopsy

USA). Baseline characteristics of HIV-infected and HIV-uninfected participants were

Detection of histologically confirmed AIN by abnormal conventional and liquid-based anal

were not significantly different.

been diagnosed on conventional cytology and 6 cases on liquid-based cytology. This is in

In summary, we demonstrated that anal cytology results using a conventional slide

intraepithelial lesions. Cytojournal. 2005 Feb 16.2(1):4. [PubMed: 15715910]

cytology. Dis Colon Rectum. 2011 Mar; 54(3):347–351. [PubMed: 21304308]

Centre, Bangkok, Thailand

Characteristics Total HIV Status P-value

MSM VCT Study (n) 153 108 45

CD4 count, cells/mm3, median (IQR) n/a 391 n/a -

HIV RNA, log10 copies/ml, n/a 1.60 n/a -

Current use of HAART, n (%) n/a 78 (44.3) n/a

Education, n (%) 76 (43.9) 57 (48.31) 19 (34.6) 0.15

Monthly income, USD, median (IQR) 360 360 390 0.72

(240 – 600) (240 – 600) (232.5 – 600)

Age at first sex, years, median (IQR) 18 18 18 0.59

Number of sex partners in the 1 (1 – 3) 1.5 (1 – 3) 1 (1 – 4) 0.51

Receptive anal sex as sexual 41 (23.7) 25 (21.2) 16 (29.1) 0.61

Consistent condom use in the 76 (43.9) 54 (45.8) 22 (40.0) 0.57

Combined HIV-infected and -uninfected MSM

Total 3 114 41 6 9 173

Anal histology Normal

Percentages are rounded and may not always add up to 100%.

Combined HIV-infected and -uninfected MSM

Cytology Histologic Conventional cytology Liquid-based cytology

ASC-US+a AIN 1+b 48 80.0 (67.7–89.2) 32 86.5 (71.2–95.5) 1.08 (0.90–1.29)

AIN 2+c 17 28.3 (17.5–41.4) 14 37.8 (22.5–55.2) 1.34 (0.75–2.38)

AIN 1+b 20 87.0 (66.4–97.2) 12 92.3 (64.0–99.8) 1.06 (0.85–1.33)

AIN 2+c 9 39.1 (19.7–61.5) 6 46.2 (19.2–74.9) 1.18 (0.54–2.57)

AIN 1+b 1 50.0 (1.3–98.7) 9 100 (66.4–100) 2.00 (0.50–8.00)

AIN 2+c 1 50.0 (1.3–98.7) 6 66.7 (29.9–92.5) 1.33 (0.31–5.75)

Cytology Histologic Conventional cytology Liquid-based cytology

AIN 1+b 40 78.4 (64.7–88.7) 25 83.3 (65.3–94.4) 1.06 (0.86–1.32)

AIN 2+c 15 29.4 (17.5–43.8) 12 40.0 (22.7–59.4) 1.36 (0.74–2.50)

AIN 2+c 8 38.1(18.1–61.6) 5 41.7 (15.2–72.3) 1.09 (0.46–2.59)

AIN 1+b 1 50.0 (1.3–98.7) 8 100 (63.1–100) 2.00 (0.50–8.00)

AIN 2+c 1 50.0 (1.3–98.7) 5 62.5 (24.5–91.5) 1.25 (0.28–5.53)

Combined HIV-infected and -uninfected MSM

Cytology Histologic Conventional cytology Liquid-based cytology

AIN 1+b 8 88.9 (51.8–99.7) 7 100 (59.0–100) 1.13 (0.89–1.42)

AIN 2+c 2 22.2 (2.8–60.0) 2 28.6 (3.7–71.0) 1.29 (0.24–6.99)

AIN 1+b 2 100 (15.8–100) 1 100 (2.5–100) 1.00 (1.00–1.00)

AIN 2+c 1 50.0 (1.3–98.7) 1 100 (2.5–100) 2.00 (0.50–8.00)

AIN 1+b 0 - 1 100 (2.5–100) -

AIN 2+c 0 - 1 100 (2.5–100) -

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